Reflex-bruxism-regulatory method: efficiency in relation to the level of emotional stress. de nivelul stresului emoţional. Abstract.

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1 20 ARTICOL DE CERCETARE Metoda reflexo-bruxismreglatoare: eficienţa în funcţie de nivelul stresului emoţional Dumitru Romaniuc 1* 1 Catedra de stomatologie terapeutică, Universitatea de Stat de Medicină şi Farmacie Nicolae Testemiţanu, Chişinău, Republica Moldova. Data primirii manuscrisului: Data acceptării spre publicare: Autor corespondent: Dumitru Romaniuc, doctorand Catedra de stomatologie terapeutică Universitatea de Stat de Medicină şi Farmacie Nicolae Testemiţanu bd. Ştefan cel Mare şi Sfânt, 165, Chişinău, Republica Moldova, MD RESEARCH ARTICLE Reflex-bruxism-regulatory method: efficiency in relation to the level of emotional stress Dumitru Romaniuc 1 1 Chair of therapeutic dentistry, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova. Manuscript received on: Accepted for publication on: Corresponding author: Dumitru Romaniuc, PhD fellow Chair of therapeutic dentistry Nicolae Testemitanu State University of Medicine and Pharmacy 165, Stefan cel Mare si Sfant ave., Chisinau, Republic of Moldova, MD Ce nu este cunoscut, deocamdată, la subiectul abordat Există mai multe metode de autoajutorare pentru diminuarea stresului emoţional şi dereglărilor motorii la pacienţii cu bruxism nocturn primar, însă acestea nu sunt utilizate pe larg din cauza eficienţei nesatisfăcătoare şi tehnicilor dificile de aplicare. O direcţie nouă este stimularea zonelor reflexogene ale sistemului stomatognat cu scop de diminuare a stresului şi dereglărilor motorii. Ipoteza de cercetare Sporirea eficienţei corecţiei dereglărilor bruxismului nocturn primar, cu transformarea bruxismului streso-patogen în bruxism streso-sanogen, ar putea fi realizată prin stimularea zonelor cutanate reflexogene ale sistemului stomatognat. Noutatea adusă literaturii ştiinţifice din domeniu În premieră, s-a demonstrat posibilitatea de coreţie a dereglărilor motorii nocturne bruxism-asociate prin stimularea zonelor reflexogene auriculare ale sistemului stomatognat. What is not known yet, about the topic There are multiple self-help methods aimed at reducing the level of emotional stress and of the motor disturbances in patients with primary sleep bruxism, but these are not widely used because of their poor efficiency and due to difficulties in applying these techniques. A new direction is represented by the stimulation of the reflexogenic zones of the stomatognathic system with the purpose of diminishing levels of stress and motor disturbance. Research hypothesis The increase in efficiency of the correction methods used for primary sleep bruxism disorders with the conversion of the stress-pathogenic bruxism into a stress-sanogenous one can be achieved by the stimulation of the reflexogenic skin areas from the stomatognathic system. Article s added novelty on the scientific topic For the first time, there has been demonstrated the possibility of correcting motor disturbances associated with sleep bruxism by stimulating the reflexogenic auricular zones from the stomatognathic system. Rezumat Introducere. Bruxismul este o patologie răspândită în jur de 85-90% din populaţia generală scrâşneşte din dinţi în anumite perioade ale vieţii. În prezent, nu există un algoritm de tratament şi autoajutorare pentru toate formele de bruxism care să permită remedierea consecinţelor bruxismului la nivelul sistemului stomatognat şi corecţia dereglărilor asociate bruxismului. Reieşind din particularităţile etiopatogenetice ale bolii, tratamentul bruxismului necesită o abordare multidisciplinară. Scopul studiului a fost elaborarea unei metode în Abstract Introduction. Bruxism is a common pathology about 85-90% of the general population grind their teeth at certain periods of their lifetime. Currently there is no universal algorithm of treatment or self-help techniques that may be used for all forms of bruxism that would allow mitigating the consequences of bruxism at the level of the stomatognathic system and that could correct the disorders associated with bruxism. Taking into account the etiopathogenetic particularities of the disease, treating bruxism would require a multidisciplinary

2 Reflex-bruxism-regulatory method MJHS 11(1)/ baza stimulării zonelor reflexogene, capabile să influenţeze manifestările bruxismului nocturn primar în condiţii de tensionare psihoemoţională (stres emoţional). Material şi metode. În studiu au fost incluşi 30 de pacienţi cu bruxism nocturn primar şi 30 de persoane sănătoase, cu vârsta de de ani. Diagnosticul bruxismului nocturn primar s-a realizat conform criteriilor internaţionale care includ: (1) anamneza; (2) aplicarea chestionarelor clinice; (3) examinarea clinică stomatologică (intraorală şi extraorală); (4) examinarea electromiografică diurnă; (5) examinarea electromiografică nocturnă. Rezultate. Există particularităţi importante ale manifestărilor bruxismului nocturn primar în funcţie de nivelul stresului emoţional. Sub influenţa metodei reflexo-bruxismreglatoare, s-a constatat o micşorare statistic semnificativă a numărului total de încleştări şi a duratei lor totale, atât la pacienţii cu nivel înalt de stres emoţional (respectiv, cu 52,4% şi 63,2%), cât şi la pacienţii fără manifestări pronunţate ale stresului (respectiv, cu 61,2% şi 67,9%). S-a demonstrat că şi la persoanele sănătoase, aflate în stare de stres emoţional, sunt prezente încleştările nocturne ale maxilarelor, care diminuează considerabil datorită aplicării metodei date. Metoda reflexo-bruxism-reglatoare la pacienţii cu bruxism nocturn primar şi la persoanele sănătoase a permis ameliorarea considerabilă a calităţii somnului nocturn. Concluzii. Metoda reflexo-bruxism-reglatoare este eficientă, simplă în realizare, nu provoacă efecte adverse şi complicaţii, micşorează considerabil numărul de încleştări nocturne şi durata totală a încleştărilor, ceea ce conduce la diminuarea severităţii episodului de bruxism şi ameliorarea somnului. Cuvinte cheie: bruxism nocturn primar, dereglări motorii, stres, zone reflexogene, autoajutorare. Introducere Actualmente, nu există un algoritm de tratament şi autoajutorare valabil pentru toate formele de bruxism, care să permită remedierea consecinţelor bruxismului la nivelul sistemului stomatognat şi corecţia dereglărilor asociate bruxismului. Reieşind din particularităţile etiopatogenetice ale bolii, tratamentul bruxismului necesită o abordare multidisciplinară. În managementul terapeutic al bruxismului nocturn (BN), pe lângă echilibrarea ocluzală şi reabilitarea protetică, se pot evidenţia următoarele componente: evitarea acţiunii cofactorilor bruxismului (alcool, cafeină, nicotină etc.), evitarea stresului şi stărilor de tensionare psihoemoţională, realizarea psihoterapiei cognitive, respectarea unor indicatori comportamentali (igiena alimentaţiei etc.), tratamentul farmacoterapeutic, tratamentul fizioterapeutic, tratamentul prin aplicarea metodelor alternative [1, 2]. Actualmente, cele mai multe investigaţii sunt consacrate metodelor de tratament complex al BN prin corecţia comportamentală, cu aplicarea metodelor de biofeedback, aplicarea gutierelor, farmacoterapia locală şi sistemică [3]. Echilibrarea ocluzală în tratamentul stomatologic complex al BN constituie o verigă esenţială, care se poate realiza prin approach. The purpose of the study was to develop a method based on the stimulation of the reflexogenic zones that may influence the degree of manifestations of primary sleep bruxism during psycho-emotional tension (emotional stress). Material and methods. In the study, there were enrolled 30 patients with primary sleep bruxism and 30 healthy individuals, aged between years. The diagnosis of primary sleep bruxism was established following international diagnostic criteria, namely: (1) anamnesis; (2) usage of clinical questionnaires; (3) clinical dental examination (intraoral and extraoral examination); (4) electromyographic examination during daytime; (5) electromyographic examination during nighttime. Results. There were observed significant features of the manifestations of primary sleep bruxism depending on the level of the emotional stress. Under the influence of reflexbruxism-regulatory method there was observed a statistically significant decrease in the total number of teeth clenches and of their total duration, both in patients with high levels of emotional stress (by 52.4% and respectively, by 63.2%), as well as in patients without profound manifestations of stress (by 61.2% and respectively, by 67.9%). It has been found that healthy individuals who are experiencing emotional stress, also clench their teeth during sleep, which significantly diminishes under the influence of the proposed method. The usage of the reflex-bruxism-regulatory method in patients with primary sleep bruxism and in healthy individuals has allowed obtaining considerable improvements in sleep quality. Conclusions. Reflex-bruxism-regulatory method is a simple, yet effective method, does not cause any side effects and complications, it significantly reduces the total number of clenches and the total clenching duration during sleep, which leads to a decrease in the severity of the bruxism episodes and improves the sleep quality. Key words: primary sleep bruxism, motor disorders, stress, reflexogenic zones, self-help technique. Introduction Currently there is no treatment algorithm or self-help techniques that can be used for all the forms of bruxism, which may allow mitigating the consequences of bruxism at the level of the stomatognathic system and that may correct the disorders that are associated with bruxism. Taking into account the etiopathogenetic peculiarities of the disease, the treatment of bruxism would require a multidisciplinary approach. In the therapeutic management of sleep bruxism (SB), besides the occlusal equilibration and prosthetic rehabilitation, there can be highlighted the following elements: avoiding known cofactors of bruxism (alcohol, caffeine, nicotine etc.); avoiding stressful or tense psycho-emotional situations; employing cognitive psychotherapy; monitoring of behavioral indices (food intake habits etc.), pharmacotherapy, physiotherapy, treatment based on methods of alternative medicine [1, 2]. Currently most of the research focuses on methods of complex treatment of SB via behavioral correction by means of biofeedback methods, by using splints, or using local and systemic pharmacotherapy [3].

3 22 Metoda reflexo-bruxism-reglatoare aplicarea gutierelor. Scopul aplicării gutierelor ocluzale este diferit: restabilirea simetriei muşchilor maseter, diminuarea spasmului muscular, prevenirea pierderilor de ţesuturi dure dentare, prevenirea traumelor ocluzale, echilibrarea prerestaurativă, protejarea noilor restaurări protetice de parafuncţii, crearea spaţiului pentru restaurarea dinţilor anteriori abraziaţi, corectarea disfuncţiei articulaţiei temporo-mandibulare, amendarea durerii artrogene, poziţionarea condilului mandibular, modificarea propriocepţiei din ligamentul periodontal [4-7]. Sub influenţa aplicării gutierelor se atestă o ameliorare clinică la pacienţii cu BN în 32-92,7% din cazuri [8]. Aplicarea gutierelor diminuează gradul asimetriei activităţii musculare, influenţează pozitiv funcţia ocluzală [7], diminuează esenţial în 74% din cazuri durerile orofaciale [4]. În unele publicaţii, se atestă o ameliorare a bruxismului sub influenţa gutierelor, însă efectele obţinute erau nestabile [9]. În alte investigaţii, rezultatele terapeutice au fost mai modeste [10]. Un studiu dedicat eficienţei gutierelor a evidenţiat că efectul terapeutic se manifestă mai pronunţat în primele nopţi ale aplicării lor, însă diminuează esenţial după 2-6 săptămâni [9]. La 20% dintre pacienţii cu BN, gutierele, din contră, sporesc activitatea muşchilor masticatori în timpul somnului [11]. Până în prezent, nu sunt elaborate criteriile de aplicare a gutierelor unii autori indică gutierele în baza manifestărilor clinice, alţii în baza modificării activităţii bioelectrice a muşchilor masticatori [12]. Se caută diferite posibilităţi de tratament farmacoterapeutic al BN. Aplicarea farmacoterapiei (antiinflamatoare, miorelaxante, benzodiazepine, beta-blocatori etc.) poate reduce frecvenţa episoadelor BN, însă indicaţiile concrete pentru aceste remedii nu au fost, deocamdată, elaborate [3, 13]. Actualmente, se studiază posibilităţile nonfarmacologice de tratament şi autoajutorare ale BN [14-17]. Rezultate pozitive au fost obţinute prin aplicarea acupuncturii, care se recomandă la pacienţii cu BN, în special, când predomină durerea şi hiperactivitatea muşchilor masticatori [18, 19]. Se consideră că pentru BN este caracteristic mai mult o activitate parafuncţională decât o disfuncţie musculară per se, ceea ce indică la o valoare mai mare a metodelor de tratament orientate la trainingul sistemului stomatognat prin aplicarea tehnicilor de tip biofeedback. Însă, aplicarea metodelor biofeedback nocturn poate conduce la întreruperea somnului, cu apariţia somnolenţei în timul zilei [13]. La unii pacienţi, se recomandă metodele de gnatotraining în tratamentul parafuncţiior muşchilor masticatori sau miogimnastica bazată pe datele EMG [20, 21]. Metodele nonfarmacologice nu sunt noi, însă rolul lor în tratatmentul complex al BN nu este clar. Adepţii teorii centrale a BN în tratamentul complex şi sistemele de autoajutorare includ, în primul rând, metodele de influenţă asupra sistemului nervos central şi consideră că, deoarece BN nu poate fi complet tratat, este necesar controlul manifestărilor bolii cu minimizarea efectelor nocive [22, 23]. Reieşind din cele relatate, scopul studiului a fost elaborarea unei metode de autoajutorare în baza stimulării zonelor reflexogene, capabile să influenţeze manifestările bruxismului nocturn primar în condiţii de tensionare psihoemoţională (stres emoţional). Occlusal equilibration represents an essential part in the complex dental treatment of SB, which is based on using oral splints. The purpose of applying occlusal splints is different: restoration of the symmetry of the masseter muscles, muscle spasm reduction, preventing the loss of hard dental tissues, prevention of occlusal trauma, pre-restorative equilibration procedures, ensuring the protection of the new prosthetic restorations against parafunctions, creating enough space for the restoration of the worn anterior teeth, correction of the temporomandibular joint dysfunction, improving joint pain, repositioning of the mandibular condyle, modification of the periodontal ligament proprioception [4-7]. Under the influence of oral splint usage there has been observed a clinical improvement in patients with SB in % of cases [8]. The use of splints decreases the asymmetry degree of the muscle activity, has a positive effect on the occlusal function [7], in 74% cases it essentially diminishes orofacial pain [4]. In some publications there has been shown an improvement of bruxism under the influence of splints, however the obtained effects were unstable [9]. In other investigations, the observed therapeutic results were more modest [10]. The results of a study, focused on investigating splint efficiency, have emphasized that the therapeutic effect occurs in a more profound way usually during the first nights of usage, but essentially diminishes in 2-6 weeks [9]. In contrast to this, in 20% of patients with SB, the splints have increased the activity of the jaw muscles during sleep [11]. So far, there have not been developed any criteria for splint usage, some authors prescribe splints based on the observed clinical manifestations, others in accordance with the modification of the bioelectric activity of the masticatory muscles [12]. There are being researched new pharmacotherapeutical solutions for SB. The application of pharmacotherapy (anti-inflammatory drugs, muscle relaxants, benzodiazepines, beta-blockers etc.) can reduce the frequency of SB episodes, but specific indications for the usage of these remedies have not been developed yet [3, 13]. Currently, there are being studied the non-pharmacological ways of treatment and the self-help techniques for SB [14-17]. Some positive results have been obtained by using acupuncture, which is recommended for patients with SB, especially when symptoms as pain and masticatory muscle hyperactivity prevail [18, 19]. It is considered that SB is more of a parafunctional activity rather than a muscular dysfunction per se; this indicates a higher usefulness for the treatment approaches that employ the training of the stomatognathic system by applying biofeedback techniques. However, the use of nocturnal biofeedback methods can lead to the interruption of sleep, and consequently to drowsiness during daytime [13]. For some patients, the recommendations would include using gnathotraining methods in the treatment of the parafunctions of masticatory muscles or doing myogymnastics based on the EMG data [20, 21]. These non-pharmacological methods are not quite novel; however, their role in the complex treatment of the SB is still unclear. The followers of central theory regarding SB etiology, would firstly include methods that may influence the central nervous system in the methods they select for the complex treatment and self-help system for SB, and they consider that

4 Reflex-bruxism-regulatory method MJHS 11(1)/ Material şi metode Planificarea cercetării s-a fundamentat pe materialele de examinare clinică a pacienţilor din Clinica Stomatologică Fala Dental, care au format loturile de studiu retrospectiv şi prospectiv. Investigaţiile şi procesul de analiză multidimensională a informaţiei a fost ghidat de Catedra de stomatologie terapeutică a Universităţii de Stat de Medicină şi Farmacie Nicolae Testemiţanu. Aprobarea etică pentru studiu a fost obţinută de la Comitetul de Etică a Cercetării al USMF Nicolae Testemiţanu (şedinţa din ) Diagnosticul BN a fost realizat conform criteriilor internaţionale, care includ: (1) anamneza; (2) aplicarea chestionarelor clinice; (3) examinarea clinică stomatologică (intraorală şi extraorală); (4) examinarea EMG timp de câteva zile; (5) înregistrarea episoadelor nocturne ale BN timp de câteva nopţi. Criterii de includere în cercetare: (1) diagnosticul clinic pozitiv al bruxismului nocturn primar, confirmat prin înregistrarea obiectivă a episoadelor nocturne; (2) prezenţa tuturor dinţilor sau edentaţii parţiale (1-3 dinţi); (3) vârsta pacienţilor de ani; (4) prezenţa acordului pacientului pentru participare în cercetare; (5) pacienţi cooperanţi. Criterii de excludere din cercetare: (1) vârsta în afara limitelor stabilite; (2) alte forme clinice ale bruxismului (afecţiuni ale sistemului nervos central, epilepsie etc.); (3) prezenţa anomaliilor şi semnelor inflamatorii în sistemul stomatognat; (4) prezenţa semnelor de afectare organică cu decompensarea activităţii muşchilor masticatori (activitatea bioelectrică conform EMG în stare de relaxare mai mică de 30 µv); (5) diferite maladii acute şi cronice în perioada de acutizare, parazitoze; (6) alcoolism, narcomanie, toxicomanie, boli psihice; (7) tratament cu remedii psihotrope, anticonvulsante, miorelaxante; (8) lipsa acordului pacientului pentru participare în cercetare; (9) pacienţii necooperanţi. În studiu au fost incluşi 30 de pacienţi cu bruxism nocturn primar şi 30 de persoane sănătoase, cu vârsta de de ani, deoarece, conform datelor din literatură, anume în acest diapazon de vârstă bruxismul se manifestă mai puternic, progresează repede, cu apariţia consecinţelor (abraziune dentară, disfuncţie temporomandibulară etc.) [20, 13]. Acest diapazon de vârstă necesită o atenţie deosebită în aspect diagnostic şi profilactic. Pentru determinarea cantitativă a trăirilor subiective emoţionale, a fost utilizată am scala vizuală analogică (VAS l. engl. visual analogue scale). Au fost realizate studii, care au demonstrat validitatea acestei metode cu scop de diagnostic şi monitorizare a dereglărilor psihoemoţionale sensibilitatea până la 76,9%, specificitatea până la 92,7%, valoarea predictivă pozitivă până la 66% şi valoarea predictivă negativă până la 88% [24]. Pentru analiza somnului de noapte, a fost aplicat chestionarul aprecierii calităţii somnului cu divizarea pacienţilor conform rezultatelor: <19 puncte patologie; de puncte dereglări limitrofe; de puncte valori normale [25]. Pentru înregistrarea cantitativă a episodului motor nocturn, a fost aplicat dispozitivul portabil SleepGuard (SG5, USA) (Figura 1). Dispozitivul a fost aplicat timp de 5 nopţi consesince SB cannot be completely cured, it is necessary to control the manifestations of the disease and to minimize its harmful effects [22, 23]. Based on the aforementioned facts, the purpose of the study was to develop a self-help method based on the stimulation of the reflexogenic zones that is capable to influence the manifestations of primary sleep bruxism in conditions of psycho-emotional tension (emotional stress). Material and methods The research planning was based on the materials obtained during clinical examination of patients at the Fala Dental Dental Clinic, these patients have formed the retrospective and prospective study groups. The investigations and the process of multidimensional analysis of the information were guided by the Chair of therapeutic dentistry of the Nicolae Testemitanu State University of Medicine and Pharmacy. Ethical approval for the study was obtained from the Research Ethics Committee of the Nicolae Testemitanu SUMPh (meeting of ) A diagnosis of SB was established in accordance with the international criteria that include: (1) anamnesis; (2) usage of clinical questionnaires; (3) dental clinical examination (intraoral and extraoral examination); (4) EMG examination during several days; (5) registration of SB episodes during several nights. Inclusion criteria used in the research: (1) positive clinical diagnosis of primary sleep bruxism, confirmed by the objective recording of nocturnal episodes; (2) the presence of all teeth or partial edentulism (up to 1-3 teeth); (3) patients aged from 18 to 50; (4) patient s agreement to participate in the research; (5) cooperative patients. Exclusion criteria used in the research: (1) age other than the limits set; (2) other clinical forms of bruxism (central nervous system disorders, epilepsy etc.); (3) the presence of inflammatory signs and abnormalities in the stomatognathic system; (4) the presence of signs of organic damage with decompensation of the masticatory muscle activity (a bioelectric activity less than 30 µv during relaxation), recorded by EMG; (5) various acute and chronic diseases during exacerbation periods, presence of parasitosis; (6) alcoholism, drug addiction, substance abuse, mental illnesses; (7) individuals undergoing treatment with psychotropic drugs, anticonvulsants, muscle relaxants; (8) absence of the patient s agreement to participate in the research; (9) uncooperative patients. In the study there were included 30 patients with primary sleep bruxism and 30 healthy individuals aged from 18 to 50, based on the data from the scientific literature, which states that in this particular age group, bruxism manifests itself stronger, and it progresses quicker to its consequences (dental abrasion, temporomandibular dysfunction etc.) [20, 13]. This age group requires special consideration from a diagnostic and prophylactic view. For the quantitative determination of the subjective emotional experiences, there was used a visual analogue scale (VAS). There are several studies that have demonstrated the validity of this method for the purpose of diagnosis and monitoring psycho-

5 24 Metoda reflexo-bruxism-reglatoare Fig. 1 Dispozitivul portabil SleepGuard (SG5, Holistic Technologies LLC, USA), aplicat în stare de veghe şi somn. Fig. 1 The SleepGuard SG5 portable device (Holistic Technologies LLC, USA) used during the state of wakefulness and during sleep. Fig. 2 Reprezentarea schematică a procedurii de stimulare a zonelor reflexogene auriculare, aplicate în metoda reflexo-bruxism reglatoare. Fig. 2 Graphic showing the procedure of stimulating the auricular reflexogenic zones, used in the reflex-bruxism-regulatory method. cutive, pentru a determina valorile medii ale numărului total de încleştări în timpul somnului nocturn (TCT l. engl. total clench time) şi perioadele totale de manifestare ale lor (TNC l. engl. total number of clenching). Înregistrarea TCT şi TNC s-a efectuat în mod automat, cu stocarea şi prelucrarea datelor obţinute. În tratamentul complex al BN, a fost aplicată metoda reflexo-bruxism-reglatoare, bazată pe stimularea zonelor reflexogene auriculare ale sistemului stomatognat, în asociere cu activarea muşchilor masticatori angrenarea forţată, ritmică, a maxilarelor [26]. Ritmul de angrenare a maxilarelor a fost stabilit, reieşind din rezultatele raportate în literatură şi care au demonstrat posibilitatea de diminuare, prin această metodă, a intensităţii stresului emoţional [27]. Esenţa metodei constă în efectuarea a 3-6 cicluri de angrenări, unde fiecare ciclu include o angrenare maximală a maxilarelor timp de 5 secunde, urmată de un repaus de 5 secunde. Execrciţiul se repetă timp de 3 minute. După exerciţiu, timp de 1-2 minute, persoana se relaxează cu ochii închişi şi cu gura semideschisă, respirând liniştit, iar în timpul angrenărilor maxilarelor, se presează lobulii auriculari şi se tracţionează în direcţie inferioară şi posterio-inferioară (Figura 2). Pentru evidenţierea particularităţilor de acţiune a metodei elaborate (metoda RBR), pacienţii cu BN şi persoanele sănătoase au fost divizate în 4 loturi: BN cu stress emotional, BN fără semne pronunţate de stres, persoane sănătoase cu stres emoţional, persoane sănătoase fără semne pronunţate de stres. Toţi pacienţii şi persoanele sănătoase au fost investigate conform unui program identic (indici motori ale episodului nocturn al bruxismului, durata somnului, indicii stresului emoţional). Toate investigaţiile au fost realizate inainte şi după aplicarea metodei RBR. Pentru aprecierea eficienţei tratamentului aplicat, am determinat coeficientul eficacităţii (β): ( F - N) b = 1-100% ( I - N) unde: I valoarea parametrilor până la tratament; F parametrii finali, după tratament; N parametrii la persoane sănătoase. emotional disorders with a sensitivity value up to 76.9%, and a specificity value up to 92.7%, a positive predictive value up to 66% and a negative predictive value up to 88% [24]. In order to analyze the night sleep we have used a questionnaire assessing sleep quality, with the separation of patients according to the results: <19 points pathology; points borderline disorder; points normal values [25]. For the quantitative registration of the motor nocturnal episodes we have used the SleepGuard SG5 portable device (Holistic Technologies LLC, USA) (Figure 1). The device is used during five consecutive nights in order to determine the average values of the total number of clenches during sleep (TNC total number of clenches) and the total duration of their manifestation (TCT total clench time). TCT and TNC recording occurs automatically with the storing and processing of the data. In the complex treatment of SB, we have used the reflexbruxism-regulatory method based on the stimulation of the auricular reflexogenic zones of the stomatognathic system in association with the activation of the masticatory muscles by the forced engagement of jaws in rhythmic movements [26]. The rhythm of the jaw movements was developed based on the results of research published in the scientific literature that have demonstrated the possibility of reducing the intensity of emotional stress by using this method [27]. The essence of the method consists in conducting 3-6 cycles of muscle engagement, whereas every cycle includes a maximum engagement of the jaws for a period of 5 seconds followed by a 5-seconds break, the procedure being repeated for 3 minutes. After the procedure is over, the patient relaxes for 1-2 minutes with his eyes closed and his mouth half-open, while breathing quietly, but during the jaw engagement steps, the auricular lobule has to be pressed and pulled in an inferior and posterior-inferior direction (Figure 2). For identifying the effects of the developed method (RBR method) we have divided patients with SB and healthy individuals into 4 groups: SB with emotional stress, SB without significant signs of stress, healthy individuals with emotional stress and healthy individuals without significant signs of stress. All patients and healthy individuals were examined according to an identical program of investigations (recording of

6 Reflex-bruxism-regulatory method MJHS 11(1)/ Conform indicelui β, a fost estimată eficienţa tratamentului: 0 lipsa efectului; 30% eficienţă slabă; 31-50% eficienţă moderată; 51-70% eficienţă exprimată; 71-99% eficienţă puternică; 100% restabilire completă a dereglărilor respective. Rezultatele obţinute au fost prelucrate cu ajutorul pachetului de programe pentru analiză statistică Statistics for Windows, Release 11,0 StatSoft, Inc. (SUA). A fost calculată media aritmetică şi eroarea standard (ES). Pentru compararea mediilor parametrilor la două eşantioane, a fost aplicat testul t- Student. Rezultate Au fost învestigaţi pacienţii cu bruxism nocturn primar în zilele când, conform termometrului stresului (VAS-stres), se obţineau cifre mai mici de 5 (grupul pacienţilor fără stres emoţional, n=30) şi în zilele când, conform termometrului respectiv, cifrele erau mai mari de 5 (grupul pacienţilor cu senzaţii subiective de stres emoţional, n=30). În felul acesta, aceeaşi pacienţi au fost investigaţi în condiţii psihoemoţionale relativ confortabile (VAS 5 pt.) şi în condiţii de autoapreciere a prezenţei stresului (VAS >5 pt.). La pacienţii cu BN şi semne de stres emoţional, în seara precedentă de aplicare a metodei RBR, s-au înregistrat parametrii: VAS-stres în valoare de 6,90±0,28 pt., iar după aplicarea metodei RBR, valorile respective s-au ameliorat cu 39,1% (p<0,001) (Figura 3). La pacienţii cu BN şi semne de stres emoţional (VAS-stres >5 pt.), în noaptea până la aplicarea metodei RBR, valorile parametrilor episodului motor erau destul de mari (TNC 95,7±6,3 un.; TCT 163,6±7,6 s.), iar în noaptea după apli- the motor indices of sleep bruxism episodes, duration of sleep, emotional stress indices). All investigations were conducted before and after using the RBR method. To assess the efficiency of the applied treatment, we have determined the efficiency coefficient, by using the formula: ( F - N) b = 1-100% ( I - N) where: I parameter values before the treatment; F final parameter values, after the treatment; N parameter values in healthy individuals. In accordance with the β index, we have determined the efficiency of the treatment: 0 lack of efficiency; 30% low efficiency; 31-50% moderate efficiency; 51-70% significant efficiency; 71-99% high efficiency; 100% complete recovery from the disorder. The obtained results were processed with the help of the statistical analysis software package Statistics for Windows, Release 11.0 StatSoft, Inc. (USA). We have determined the arithmetical mean and standard error (SE). We used Student s t-test to compare the parameter averages of the two samples. Results There were investigated patients with primary sleep bruxism, during the days when according to the stress thermometer (VAS-stress) there were observed figures lower than 5 points (group of patients without emotional stress, n=30) and on the days when according to the stress thermometer, the value of the index was higher than 5 (group of patients with subjective sensations of emotional stress, n=30). Thus, the same patients were investigated in conditions of a relatively Fig. 3 Valorile VAS-stres la persoanele sănătoase şi la pacienţii cu bruxism nocturn primar, sub influenţa metodei reflexo-bruxism-reglatoare, în funcţie de nivelul stresului emoţional. Notă: pe vericală valoarea VAS-stres, pt. Diferenţele statistice după aplicarea metodei RBR vs. până la aplicarea metodei RBR marcate drept: ( p<0,001); vs. persoanele sănătoase, în stare de confort relativ ( xxx p<0,001). Fig. 3 VAS-stress values in healthy individuals and in patients with primary sleep bruxism under the influence of the reflex-bruxism-regulatory method in relation to the level of emotional stress. Note: vertically VAS-stress, pt.; statistically significant differences after using the RBR method vs. before applying the RBR method ( p<0.001); vs. healthy individuals in a state of relative comfort (xxx p<0.001).

7 26 Metoda reflexo-bruxism-reglatoare Fig. 4 Numărul de încleştări nocturne şi durata lor totală la pacienţii cu bruxism nocturn primar sub influenţa metodei reflexo-bruxismreglatoare, în funcţie de nivelul stresului emoţional. Notă: pe verticală numărul total de încleştări (TNC, un.) şi durata lor totală (TCT, s.). Diferenţele statistice după aplicarea metodei RBR vs. până la aplicarea metodei RBR ( p<0,001); vs. persoane sănătoase, în stare de confort relativ ( xxx p<0,001). Fig. 4 Number of nocturnal clenches and their total duration in patients with primary sleep bruxism under the influence of reflex-bruxism-regulatory method in relation to the level of emotional stress. Note: vertically total number of clenches (TNC, un.) and total clench time (TCT, s); statistically significant differences after using the RBR method vs. before applying the RBR method ( p<0.001); vs. healthy individuals in a state of relative comfort (xxx p<0.001). carea metodei RBR, valorile respective au diminuat statistic semnificativ (TNC cu 52,4% iar TCT cu 63,2% (Figura 4). Un indice important al eficienţei este coeficientul β, care reflectă rezultatul tratamentului în aspect tridimensional (valorile până la tratament/valorile după tratament/valorile normale). Eficacitatea corecţiei (coeficientul β) episodului nocturn la pacienţii cu BN şi semne de stres emoţional (VAS-stres >5 pt.) sub influenţa metodei RBR a fost de 56,0% pentru TNC şi de 65,0%, pentru TCT. Aceste valori reflectă o eficacitate exprimată. Durata somnului în noaptea înainte de aplicarea metodei RBR a fost de 7,2±1,6 ore, iar după aplicarea metodei de 7,8±1,5 ore. Se observă o tendinţă de sporire a duratei somnului, însă fără deosebiri statistic semnificative. Calitatea somnului la pacienţii cu BN şi stres, înainte de aplicarea metodei RBR, a constituit 17,1±1,3 pt., iar după aplicarea metodei de 22,7±1,5 pt. (p<0,01). Deci, calitatea somnului s-a ameliorat cu 32,7%. La pacienţii cu BN fără semne de stres emoţional, aplicarea metodei RBR, de asemenea, a provocat modificări considerabile ale indicilor psihoemoţionali: înaintea aplicării metodei RBR, indicii VAS-stres au avut valorile de 2,6±0,65 pt., iar după realizarea metodei RBR, indicii au evoluat spre o ameliorare cu 11,5% (p>0,05) (Figura 3). La pacienţii cu BN fără semne de stres emoţional, valorile indicilor motorii ale episodului nocturn până la aplicarea metodei RBR, au constituit: TNC 112,8±5,7 un.; TCT 182,7±7,7 s.; după aplicarea metodei RBR, aceşti indici au diminuat considerabil (p<0,001): TNC cu 61,2%, iar TCT cu 67,9% (Figura 4). Eficacitatea corecţiei (coeficientul β) la pacienţii fără semne de stres emoţional a constituit pentru TNC 63,0% şi 69,0%, respectiv, pentru TCT. comfortable psycho-emotional state (VAS 5 pt.) and in conditions of self-assessment of stress (VAS >5 pt.). In patients with SB and signs of emotional stress, during the night before the application of the RBR method, there were observed the following values: a VAS-stress value of 6.9±0.28 pt., and after using the RBR method, the respective values have improved by 39.1% (p<0.001) (Figure 3). In patients with SB and signs of emotional stress (VASstress >5 pt.), during the night before using the RBR method, the motor episode indices were rather high (TNC 95.7±6.3 un.; TCT 163.6±7.6 s), but during the night after applying the RBR method, these indices decreased statistically significant (TNC by 52.4%, TCT by 63.2%) (Figure 4). An important index of efficiency is the β coefficient, which reflects the treatment result from a three-dimensional aspect (values before the treatment/values after the treatment/normal values). The effectiveness of correction (β coefficient) of nocturnal episodes in patients with SB and with signs of emotional stress (VAS-stress >5 pt.) under the influence of the RBR method is 56.0% for TNC and 65.0% for TCT. These values reflect a significant efficiency. The duration of night sleep before using the RBR method was 7.2±1.6 hours, and after applying the aforementioned method 7.8±1.5 hours. There was observed a tendency of extending the sleep duration; however the observed differences were not statistically significant. The sleep quality in patients with SB and stress before the application of the RBR method was 17.1±1.3 pt., but after using the method 22.7±1.5 pt. (p<0.01). Thus, the quality of sleep was improved by 32.7%. In patients with SB without any signs of emotional stress the application of the RBR method also caused considerable changes of the psycho-emotional indices: before using the

8 Reflex-bruxism-regulatory method MJHS 11(1)/ Fig. 5 Numărul de încleştări nocturne şi durata lor totală la persoane sănătoase, sub influenţa metodei reflexo-bruxism-reglatoare, în funcţie de nivelul stresului emoţional. Notă: pe verticală numărul total de încleştări (TNC, un.) şi durata lor totală (TCT, s.). Diferenţele statistice după aplicarea metodei RBR vs. până la aplicarea metodei RBR ( p<0,05; p<0,001); vs. persoane sănătoase, în stare de confort relativ ( x p<0,05; xxx p<0,001). Fig. 5 Number of nocturnal clenches and their total duration in healthy individuals under the influence of reflex-bruxism-regulatory method in relation to the level of emotional stress. Note: vertically total number of clenches (TNC, un.) and their total duration (TCT, s); statistically significant differences after using the RBR method vs. before applying the RBR method ( p<0.05; p<0.001); vs. healthy individuals in a state of relative comfort ( x p<0.05; xxx p<0.001). Durata somnului nocturn nu s-a modificat statistic semnificativ (până la aplicarea metodei RBR 7,6±1,5 ore, iar după aplicarea metodei 7,1±0,8 ore). La pacienţii cu BN şi VAS-stres <5 pt., înainte de aplicarea metodei RBR, calitatea somnului a constituit 19,3±1,5 pt., iar după aplicarea metodei 21,8±1,4 pt. (p>0,05). La persoanele sănătoase cu semne de stres emoţional, înaintea influenţei metodei RBR, VAS-stres a constituit 5,8±0,41 pt.; aplicarea metodei RBR a indus modificări pozitive diminuarea stresului cu 56,9% (Figura 5). Indicii episodului motor, cu semne de încleştare a maxilarelor, s-a manifestat şi la persoanele sănătoase, în stare de stres emoţional pronunţat (VAS-stres >5 pt.) (Figura 5). Înainte de metoda RBR, TNC a constituit 12,9±2,4 un.; TCT a avut valori de 16,25±0,59 s., iar după aplicarea metodei RBR, aceşti indici au diminuat considerabil: TNC cu 25,6%; TCT cu 45,7%. La persoanele sănătoase, metoda RBR a diminuat manifestările motorii ale episoadelor de încleştare a maxilarelor, cu influenţă mai puternică asupra duratei totale a încleştărilor nocturne. Durata somnului sub influenţa metodei RBR nu s-a modificat considerabil (înaintea aplicării metodei RBR a consituit 7,6±1,0 ore, iar după aplicarea metodei 7,1±0,9 ore). La persoanele sănătoase, în prezenţa stresului, înainte de aplicarea metodei RBR, calitatea somnului a constituit 22,8±1,3 pt., iar după aplicare metodei 26,6±1,2 pt. (p<0,05). La persoanele sănătoase, fără semne de stres emoţional, aplicarea metodei RBR a condus la o armonizare a funcţiilor psihoemoţionale: până la aplicarea metodei RBR, VAS-stres a RBR method, the VAS-stress indices had values of 2.6±0.65 pt., but after applying the RBR method the indices increased by 11.5% (p>0.05) (Figure 3). In patients with SB without any signs of emotional stress the values of motor indices of the nocturnal episodes before using the RBR method were: TNC 112.8±5.7 un.; TCT 182.7±7.7 s; after applying the RBR method these indices have decreased considerably (p<0.001): TNC by 61.2% and TCT by 67.9% (Figure 4). The correction efficiency (β coefficient) in patients without any signs of emotional stress was 63.0% for TNC and 69.0% for TCT. The duration of sleep did not significantly modify statistically (before using the RBR method 7.6±1.5 hours, but after applying the RBR method 7.1±0.8 hours). In patients with SB and VAS-stress <5 pt. before using the RBR method, the quality of sleep was 19.3±1.5 pt., but after applying this method 21.8±1.4 pt. (p>0.05). In healthy individuals with signs of emotional stress before the RBR method, the value of VAS-stress was 5.8±0.41 pt.; after using the RBR method, it has caused some positive modifications a reduction of stress by 56.9% (Figure 5). The indices of motor episodes, with signs of jaw clenching occur in healthy individuals in conditions of strong emotional stress (VAS-stress >5 pt.) (Figure 5). Before the application of the RBR method, TNC was 12.9±2.4 un.; TCT had a value of 16.25±0.59 s, but after using the RBR method, these indices have decreased considerably: TNC by 25.6%; TCT by 45.7%. In healthy individu-

9 28 Metoda reflexo-bruxism-reglatoare constituit 3,2±0,39 pt.; după aplicarea metodei, intensitatea stresului emoţional a diminuat cu 12,5% (Figura 3). La persoanele sănătoase, fără semne de stres emoţional, s-a atestat un număr foarte mic de încleştări în timpul somnului: înainte de aplicarea metodei RBR, TNC a constituit 3,4±0,95 un., iar TCT 3,6±0,68 s.; după aplicarea metodei RBR, indicii respectivi s-au modificat astfel: TNC 3,3±0,1 un.; TCT 1,81±0,32 s. S-a observat că şi la persoanele sănătoase, fără semne de stres emotional, aplicarea metodei RBR reduce durata totală de încleştare cu 49,7% (p<0,05). Durata somnului de noapte nu s-a modificat considerabil, fiind de 7,3±0,6 ore înaintea aplicării metodei RBR şi de 7,1±0,5 ore după aplicarea metodei. La persoanele sănătoase, fără manifestări de stres emoţional, înainte de aplicarea metodei RBR, calitatea somnului a constituit 23,6±1,4 pt., iar după aplicarea metodei 25,3±1,5 pt. (p>0,05). Discuţii Rezultatele obţinute demonstrează că există particularităţi importante ale manifestărilor BN la pacienţi, în funcţie de nivelul stresului emoţional şi aplicarea metodei RBR. S-a demonstrat că şi la persoanele sănătoase, în stare de stres emoţional, sunt prezente încleştările nocturne ale maxilarelor, care diminuează considerabil sub influenţa metodei RBR. Bruxismul, conform opiniei multor autori, este considerat a fi un răspuns fizic (somatic) la un stres emoţional, însă rezultatele obţinute în ultimii ani reflectă o interdependenţă mult mai complexă ale acestor fenomene [13, 27, 28]. În experienţe pe animale, a fost demonstrat că stările de stres sunt asociate cu contacte ocluzale mai frecvente şi mişcări ale mandibulei, asemănătoare cu cele apărute în BN [29]. Stresul cronic provoacă modificări severe ale reflexelor maseterice [30] şi conduce la apariţia disfuncţiilor musculare în sistemul stomatognat, de la 34% până la 46,2% din cazuri [31]. Actualmente, se aplică multe metode şi tehnologii de diminuare a stresului emoţional la pacienţii cu BN [20, 32]. O metodă de autoajutorare la pacienţii cu BN poate fi considerată benefică atunci, când, pe lângă amelioararea stării psihoemoţionale, ea are o acţiune exprimată şi asupra activităţii muşchilor masticatori, cu diminuarea manifestărilor episodului de bruxism [13, 17, 23]. Reieşind din cele relatate, ne-am propus drept obiectiv elaborarea unei metode capabile să influenţeze mai puternic dereglările psihomotorii la pacienţii cu BN în condiţii de tensionare psihoemoţională (stres emoţional). Totodată, metoda propusă trebuie să fie accesibilă, simplă şi eficientă. În căutarea acestei tehnologii, ne-am axat pe posibilităţile terapeutice ale zonelor reflexogene cutanate, asociate cu sistemul stomatognat [19, 33] (Figura 6). Zona lobulului auricular prezintă un interes deosebit pentru specialiştii din stomatologie deoarece, în baza investigaţiilor neurologice, neurostomatologice şi neurofiziologice, a fost demonstrat că proiecţia structurilor sistemului stomatognat pe lobulul auricular poate fi explicată prin particularităţile inervaţiei acestei zone nervul facial (VII), trigemen (V), glosofaringian (IX), vagus (X) şi plexul cervical (C 2 C 3 ) [19, 33]. Prezenţa terminaţiunilor acestor nervi crează condiţii faals, the RBR method has led to the decrease of the motor manifestations of jaw clenching episodes with a stronger influence on the total duration of nocturnal clenching. The duration of sleep has not significantly changed under the influence of the RBR method (before applying the RBR method it was 7.6±1.0 hours, but after using the aforementioned method 7.1±0.9 hours). In healthy individuals with signs of emotional stress before using the RBR method, the quality of sleep was 22.8±1.3 pt. and after applying the method 26.6±1.2 pt. (p<0.05). In healthy individuals without any signs of emotional stress the usage of the RBR method has led to a harmonization of the psycho-emotional functions: before using the RBR method, VASstress had a value of 3.2±0.39 pt.; after applying the method the intensity of the emotional stress decreased by 12.5% (fig. 3). In healthy individuals without any signs of emotional stress, there occurs a very small number of clenches during sleep: before using the RBR method, TNC was 3.4±0.95 un., and TCT 3.6±0.68 s; after applying the RBR method these indices have changed: TNC 3.3±0.1 un.; TCT 1.81±0.32 s. It was observed that in healthy individuals without any signs of emotional stress, the RBR method reduces the total period of clenching by 49.7% (p<0.05). The sleep duration hasn t changed significantly, being 7.3±0.6 hours before applying the RBR method and 7.1±0.5 hours after using the method. In healthy individuals without any signs of emotional stress before using the RBR method, the quality of sleep was 23.6±1.4 pt. but after its application 25.3±1.5 pt. (p>0.05). Discussions The obtained results demonstrate that there are important peculiarities of the SB manifestations depending on the level of emotional stress and on the usage of the RBR method. It has been demonstrated that in healthy individuals that are in a state of emotional stress, there occurs nocturnal jaw clenching as well, which decreases significantly under the influence of the RBR method. According to the opinion of many researchers, bruxism is a physical (somatic) response to an emotional stress, however the results that have recently been obtained reflect a more complex interdependence of these phenomena [13, 27, 28]. In animal experiments, it was shown that stress is associated with more frequent occlusal contacts and jaw movements, similar to those that occur in SB [29]. Chronic stress causes severe modifications in the masseter reflexes [30] and leads to the appearance of muscular dysfunctions in the stomatognathic system in 34%-46.2% cases [31]. Currently there are being used a lot of methods and technologies in order to reduce emotional stress in patients with SB [20, 32]. A self-help method in patients with SB can be considered to be beneficial when besides the improvement of the psycho-emotional state, the method has a noticeable effect upon the activity of the masticatory muscles with a reduction of the number of manifestations of bruxism episodes [13, 17, 23]. Based on the facts mentioned above, we have set as the objective of the study the development of a method that is capa-

10 Reflex-bruxism-regulatory method MJHS 11(1)/ Fig. 6 Proiecţia structurilor cerebrale şi ale sistemului stomatognat pe lobulul pavilionului auricular [19, 33]. Notă: 1 hipofiza; 2 hipotalamusul; 3 formaţia reticulară; 4 sistemul limbic; 5 talamusul; 6 lobul frontal; 7 proiecţia corticală vestibulară; 8 proiecţia corticală auditivă; 9 proiecţia corticală vizuală; 10 proiecţia corticală motorie; 11 proiecţia corticală somatoviscerală. Fig. 6 The projection areas of the brain structures and stomatognathic system on the lobule of the auricular pavilion [19, 33]. Note: 1 pituitary; 2 hypothalamus; 3 reticular formation; 4 limbic system; 5 thalamus; 6 frontal lobe; 7 vestibular cortical projections; 8 auditory cortical projection; 9 cortical visual projection; 10 cortical motor projection; 11 cortical somato-visceral projection. vorabile pentru modificarea esenţială a activităţii structurilor trunchiului cerebral, implicate în reglarea activităţii sistemului stomatognat. În baza conexiunilor aferente-eferente a nervilor menţionaţi, există multiple căi neurogene de interacţiune, care influenţază mecanismele patogenetice ale BN (sensibilitate nociceptivă, hiperactivitatea muşchilor masticatori, activitate reflexo-ocluzală etc.), dar şi mecanismele sanogene la această categorie de pacienţi. Pornind de la posibilitatea teoretică de a influenţa activitatea sistemului stomatognat prin acţiunea asupra zonelor reflexogene auriculare, a fost elaborată o tehnică specială, numită metoda reflexo-bruxism-reglatoare (metoda RBR). Primul component al acestei metode este acţiunea mecanică (masarea, întinderea, presarea, frecarea) asupra lobulului auricular, cu scop de a influenţa prin nervii respectivi asupra structurilor trunchiului cerebral, implicate în reglarea activităţii sistemului stomatognat. Al doilea component include mişcările ritmice ale mandibulei, cu angrenarea forţată a maxilarelor. Ideea principală este realizarea acţiunii asupra lobulului auricular concomitent cu activizarea muşchilor masticatori, pentru a crea condiţii fiziologice mai favorabile de interacţiune ale zonelor reflexogene auriculare cu structurile sistemului stomatognat. S-a demonstrat, că angrenarea periodică forţată la pacienţii cu BN poate reduce nivelul de cortizol în salivă şi, deci, diminuează nivelul stresului emoţional [27]. Rezultatele noastre au demonstrat ca BN este asociat cu un nivel înalt de stres emoţional, corecţia căruia conduce la diminuarea esenţială a dereglărilor nocturne motorii şi la ameliorarea somnului de noapte. Important este că stările de stres emoţional conduc la apariţia încleştărilor nocturne ale maxilarelor, atât la pacienţii cu BN, cât şi la persoanele sănătoase, ceea ce confirmă teoria centrală a etiopatogenezei BN, cu implicarea factorilor psihogeni. În grupul pacienţilor cu BN fără semne de stres emoţional, au fost depistate efecte pozitive care, în linii generale, se aseamănă cu cele obţinute la pacienţii cu BN şi stres emoţional. ble of influencing the psychomotor disorders in a more powerful way in patients with SB that are under psycho-emotional tension (emotional stress). The suggested method should be accessible, simple, and effective at the same time. In pursuit of such a technology, we have focused on the therapeutic possibilities of the reflexogenic cutaneous zones, associated with the stomatognathic system [19, 33] (Figure 6). The zone of the auricular lobule is of a particular interest to the dental specialists, due to the fact that during neurological, neuro-dental and neuro-physiological investigations it has been proved that the projection of the structures, belonging to the stomatognathic system on the auricular lobule can be explained by the innervation peculiarities of this area the facial nerve (VII), the trigeminal nerve (V), the glossopharyngeal nerve (IX), the vagus nerve (X) and the cervical plexus (C 2 C 3 ) [19, 33]. The presence of these nerve endings create favorable conditions for the activity of the brainstem structures that are involved in the regulation of the activity of the stomatognathic system. On the basis of afferent-efferent connections of the mentioned nerves there exist multiple neurogenic ways of interaction that influence the SB pathogenic mechanisms (the nociceptive sensitivity, hyperactivity of the masticatory muscles, the reflex-occlusal activity, etc.) and sanogenic mechanisms observed in this category of patients. Starting from the theoretical possibility of influencing the activity of the stomatognathic system by influencing the auricular reflexogenic zones we have elaborated a special technology called reflex- bruxism-regulatory method (RBR method). The first element of this method is the mechanical action (massage, stretching, pressing, rubbing) exerted on the ear lobe with the purpose of influencing the brainstem nerve structures, involved in the activity of regulating the stomatognathic system. The second element includes the rhythmic movements of the mandible, with the forced jaw engagement. The main idea is to accomplish an action on the ear lobe and at the same time to activate the masticatory muscles in order to create more favorable condi-

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